Changes in liquid emptying in migraine patients: diagnosed with liquid phase gastric emptying scintigraphy

The Gut-brain Connection and Episodic Migraine: an Update

PURPOSE OF REVIEW

Historical evidence suggests a shared underlying etiology for migraine and gastrointestinal (GI) disorders that involves the gut-brain axis. Here we provide narrative review of recent literature on the gut-brain connection and migraine to emphasize the importance of tailoring treatment plans for patients with episodic migraine who experience GI comorbidities and symptoms.

RECENT FINDINGS

Recent population-based studies report the prevalence of migraine and GI disorders as comorbidities as well as overlapping symptomology. American Headache Society (AHS) guidelines have integrated GI symptoms as part of migraine diagnostic criteria and recommend nonoral therapies for patients with GI symptoms or conditions. Nasal delivery is a recommended nonoral alternative; however, it is important to understand potential adverse events that may cause or worsen GI symptoms in some patients due to the site of drug deposition within the nasal cavity with some nasal therapies. Lastly, clinical perspectives emphasize the importance of identifying GI symptoms and comorbidities in patients with episodic migraine to best individualize migraine management. Support for an association between the gut-brain axis and migraine continues to prevail in recent literature; however, the relationship remains complex and not well elucidated. The presence of GI comorbidities and symptoms must be carefully considered when making treatment decisions for patients with episodic migraine.

Gastroparesis and Gastroparesis Syndromes as Neuromuscular Disorders

Gastroparesis syndromes (GpS) are a spectrum of disorders presenting with characteristic symptoms increasingly recognized as being gastrointestinal (GI) neuromuscular disorders (NMDs). This review focuses on GpS as a manifestation of neurologic disorders of GI NMD. GpS can be associated with systemic abnormalities, including inflammatory, metabolic, and serologic disorders, as well as autoimmune antibodies via nerve and muscle targets in the GI tract, which can be treated with immunotherapy, such as intravenous immunoglobulin. GpS are associated with autonomic (ANS) and enteric (ENS) dysfunction. Disorders of ANS may interact with the ENS and are the subject of continued investigation. ENS disorders have been recognized for a century but have only recently begun to be fully quantified. Anatomic structural changes in the GI tract are increasingly recognized in GpS. Detailed descriptions of anatomic changes in GpS, and their correlation with physiologic findings, have opened a new era of investigation. The management of GpS, when viewed as GI NMD, has shifted the paradigms of both diagnosis and treatment. This article concludes with current approaches to GpS directed at underlying neuromuscular pathology.

Migraine and Gastroparesis

PURPOSEOF REVIEW

Migraine is a chronic and disabling disease affecting a significant proportion of the world's population. There is evidence that gastroparesis, a gastrointestinal (GI) dysmotility disorder in which transit of gastric contents is delayed, can occur in the setting of migraine. This article aims to review recent literature on overlap in the pathophysiology and clinical manifestations of migraine and gastroparesis and highlight management considerations when these disorders coexist.

RECENT FINDINGS

There has been increasing recognition of the importance of the connection between the GI tract and the brain, and mounting evidence for the overlap in the pathophysiology of migraine and gastroparesis specifically. There exists a complex interplay between the central, autonomic, and enteric nervous systems. Studies show that gastroparesis may be present during and between acute migraine attacks necessitating modification of management to optimize outcomes. Gastric dysmotility in the setting of migraine can impact absorption of oral migraine medications and alternate formulations should be considered for some patients. Noninvasive vagus nerve stimulation has been FDA cleared for migraine treatment and is also being studied in gastroparesis. Dysfunction of the autonomic nervous system is a significant feature in the pathophysiology of gut motility and migraine, making treatments that modulate the vagus nerve attractive for future research.

A link between gastrointestinal disorders and migraine: Insights into the gut-brain connection

Background

Migraine is a complex, multifaceted, and disabling headache disease that is often complicated by gastrointestinal (GI) conditions, such as gastroparesis, functional dyspepsia, and cyclic vomiting syndrome (CVS). Functional dyspepsia and CVS are part of a spectrum of disorders newly classified as disorders of gut–brain interaction (DGBI). Gastroparesis and functional dyspepsia are both associated with delayed gastric emptying, while nausea and vomiting are prominent in CVS, which are also symptoms that commonly occur with migraine attacks. Furthermore, these gastric disorders are comorbidities frequently reported by patients with migraine. While very few studies assessing GI disorders in patients with migraine have been performed, they do demonstrate a physiological link between these conditions.

Objective

To summarize the available studies supporting a link between GI comorbidities and migraine, including historical and current scientific evidence, as well as provide evidence that symptoms of GI disorders are also observed outside of migraine attacks during the interictal period. Additionally, the importance of route of administration and formulation of migraine therapies for patients with GI symptoms will be discussed.

Methods

A literature search of PubMed for articles relating to the relationship between the gut and the brain with no restriction on the publication year was performed. Studies providing scientific support for associations of gastroparesis, functional dyspepsia, and CVS with migraine and the impact these associations may have on migraine treatment were the primary focus. This is a narrative review of identified studies.

Results

Although the association between migraine and GI disorders has received very little attention in the literature, the existing evidence suggests that they may share a common etiology. In particular, the relationship between migraine, gastric motility, and vomiting has important clinical implications in the treatment of migraine, as delayed gastric emptying and vomiting may affect oral dosing compliance, and thus, the absorption and efficacy of oral migraine treatments.

Conclusions

There is evidence of a link between migraine and GI comorbidities, including those under the DGBI classification. Many patients do not find adequate relief with oral migraine therapies, which further necessitates increased recognition of GI disorders in patients with migraine by the headache community.

No Gastrointestinal Dysmotility in Transgenic Mouse Models of Migraine

OBJECTIVE

To determine whether transgenic mouse models of migraine exhibit upper gastrointestinal dysmotility comparable to those observed in migraine patients.

BACKGROUND

There is considerable evidence supporting the comorbidity of gastrointestinal dysmotility and migraine. Gastrointestinal motility, however, has never been investigated in transgenic mouse models of migraine.

METHODS

Three transgenic mouse strains that express pathogenic gene mutations linked to monogenic migraine-relevant phenotypes were studied: CADASIL (Notch3-Tg88), FASP (CSNK1D-T44A), and FHM1 (CACNA1A-S218L). Upper gastrointestinal motility was quantified by measuring gastric emptying and small intestinal transit in mutant and control animals. Gastrointestinal motility was measured at baseline and after pretreatment with 10 mg/kg nitroglycerin (NTG).

RESULTS

No significant differences were observed for gastric emptying or small intestinal transit at baseline for any of the 3 transgenic strains when compared to appropriate controls or after pretreatment with NTG when compared to vehicle.

CONCLUSIONS

We detected no evidence of upper gastrointestinal dysmotility in mice that express mutations in genes linked to monogenic migraine-relevant phenotypes. Future studies seeking to understand why humans with migraine experience delayed gastric emptying may benefit from pursuing other modifiers of gastrointestinal motility, such as epigenetic or microbiome-related factors.

Evaluating Mean Level and Within-Person Consistency in Migraine Pain Intensity and Migraine-Related Disability for AVP-825 vs Oral Sumatriptan: Results from the COMPASS Study, A Randomized Trial

BACKGROUND

Consistency of response across multiple attacks is typically measured as the proportion of study participants who achieve a categorical endpoint over a specified number of attacks (ie, 2-hour pain-free response in 2 of 3 attacks). We applied a novel analytic approach for measuring consistency of response in the acute treatment of episodic migraine using data from the COMPASS study.

METHODS

The COMPASS study (NCT01667679) was a multiple attack crossover study which compared AVP-825, a Breath Powered^® intranasal delivery system for low-dose sumatriptan powder (22 mg), with 100-mg oral sumatriptan tablets in the acute treatment of migraine. Participants were 18-65 years old, met ICHD-2 criteria for migraine with or without aura, and had migraine for ≥1 year prior to screening. They were instructed to treat up to 5 migraine attacks with each treatment and recorded migraine pain intensity and disability data at pre-dose and 10, 15, 30, 45, 60, 90, and 120 minutes post-dose for each attack. We explored the mean level and within-person variability (WPV; a measure of consistency) in migraine pain intensity and migraine-related disability across multiple attacks after treatment with AVP-825 (22 mg) vs oral sumatriptan (100 mg) using location scale mixed-effects models (LSMEMs). LSMEMs controlled for pre-dose pain/disability, demographics, treatment sequence, and treatment period.

RESULTS

The mean age was 40 and the sample was 84.6% women. Participants (N = 259) treated an average of 6.8 attacks each during the course of the study. Attacks treated with AVP-825 showed significantly lower mean pain intensity and mean disability from 10 to 90 minutes post-dose (effect sizes ranged from -0.09 to -0.29 and P values ranged from P < .0001 to P = .01). WPV was significantly greater at 10-15 minutes (WPV ratios ranged from 1.20 to 1.58 and P values ranged from P < .0001 to P = .04) but significantly reduced from 45 to 120 minutes for attacks treated with AVP-825 compared to oral sumatriptan (WPV ratios ranged from 0.67 to 0.81 and P values ranged from P < .0001 to P = .03).

CONCLUSIONS

LSMEMs demonstrate that treatment with AVP-825 is associated with lower average migraine pain intensity and disability from 10 to 90 minutes and greater within-person consistency across multiple migraine attacks (reduced WPV) from 45 to 120 minutes post-dose compared to oral sumatriptan. These findings may reflect the more rapid and consistent absorption of sumatriptan using AVP-825. Increased WPV with AVP-825 in the first 15 minutes likely reflects the earlier onset of treatment effects with the device compared to oral sumatriptan. LSMEMs show promise as a novel approach for assessing and comparing consistency of treatment response in migraine trials.

Migraine, Cyclic Vomiting Syndrome, and Other Gastrointestinal Disorders

PURPOSE OF REVIEW

Cyclic vomiting syndrome (CVS) is a chronic functional gastrointestinal disorder characterized by episodic nausea and vomiting and is diagnosed using Rome IV criteria. CVS is being recognized more frequently in adults with a prevalence of 2%. It is associated with several functional disorders like autonomic dysfunction, anxiety, and depression, but the strongest association is with migraine. We will elucidate the close relationship between migraine and CVS and briefly discuss its association with other gastrointestinal disorders.

RECENT FINDINGS

We highlight similarities in pathophysiology, clinical presentation, and response to medications between CVS and migraine (tricyclic antidepressants, triptans, antiepileptics). We also discuss novel therapies like CGRP inhibitors which are effective in migraine and have potential for adaptation in patients with CVS. Using migraine as a template should enable investigators to elucidate the mechanisms underlying this disorder, develop novel therapies, and direct future research in CVS.

Gastrointestinal disorders associated with migraine: A comprehensive review

Migraine is a recurrent and commonly disabling primary headache disorder that affects over 17% of women and 5%-8% of men. Migraine susceptibility is multifactorial with genetic, hormonal and environmental factors all playing an important role. The physiopathology of migraine is complex and still not fully understood. Many different neuropeptides, neurotransmitters and brain pathways have been implicated. In connection with the myriad mechanisms and pathways implicated in migraine, a variety of multisystemic comorbidities (e.g., cardiovascular, psychiatric and other neurological conditions) have been found to be closely associated with migraine. Recent reports demonstrate an increased frequency of gastrointestinal (GI) disorders in patients with migraine compared with the general population. Helicobacter pylori infection, irritable bowel syndrome, gastroparesis, hepatobiliary disorders, celiac disease and alterations in the microbiota have been linked to the occurrence of migraine. Several mechanisms involving the gut-brain axis, such as a chronic inflammatory response with inflammatory and vasoactive mediators passing to the circulatory system, intestinal microbiota modulation of the enteric immunological milieu and dysfunction of the autonomic and enteric nervous system, have been postulated to explain these associations. However, the precise mechanisms and pathways related to the gut-brain axis in migraine need to be fully elucidated. In this review, we survey the available literature linking migraine with GI disorders. We discuss the possible physiopathological mechanisms, and clinical implications as well as several future areas of interest for research.

Delayed absorption of many (paracetamol, aspirin, other NSAIDs and zolmitriptan) but not all (sumatriptan, rizatriptan) drugs during migraine attacks and most likely normal gastric emptying outside attacks. A review

Background In most pharmacokinetic studies, the oral absorption of drugs is impaired during migraine attacks but exceptions occur. A study on gastric emptying using gastric scintigraphy indicated that gastric stasis also occurs interictally in migraine. These studies were reviewed critically. Results In seven studies, mainly investigating NSAIDs and analgesics, the early absorption of the drugs during 112 migraine attacks was delayed. The absorption of sumatriptan is usual in therapeutic doses, and rizatriptan was normal during 131 migraine attacks. The interictal gastric stasis observed using gastric emptying scintigraphy (GES) with solids ( n = 13) could not be confirmed in a larger study ( n = 27) using the same method. Also gastric emptying measured with GES with liquids ( n = 7) and epigastric impedance ( n = 64) was normal outside migraine attacks. Conclusions and possible clinical implications Drug absorption is not generally impaired during migraine attacks. Gastric emptying is most likely normal in the majority of migraine patients outside attacks. Prokinetic and antiemetic drugs such as metoclopramide and domperidone should not be routinely combined with oral analgesics or oral triptans. If, however, nausea is severe or vomiting occurs, treatment with an antiemetic with proven efficacy on the nausea of migraine can be indicated.

What the Gut Can Teach Us About Migraine

During gestation, cells of the brain and gut develop almost simultaneously into the central nervous system (CNS) and enteric nervous system (ENS), respectively. They remain connected via the vagal nerve lifelong. While it is well known that the brain sends signal to the gut, communication is in fact bidirectional. Just as the brain can modulate gut functioning, the gut, and likely what we ingest, can in fact influence our brain functioning. We will first review both gastrointestinal (GI) function and migraine pathophysiology and then discuss evidence linking the migraine brain to various GI disorders. Lastly, we discuss the effects of gut microbiota on brain functioning and speculate how the gut and particularly diet may affect migraine.

Spectrum of complicated migraine in children: A common profile in aid to clinical diagnosis

Complicated migraine encompasses several individual clinical syndromes of migraine. Such a syndrome in children frequently presents with various neurological symptoms in the Emergency Department. An acute presentation in the absence of headache presents a diagnostic challenge. A delay in diagnosis and treatment may have medicolegal implication. To date, there are no reports of a common clinical profile proposed in making a clinical diagnosis for the complicated migraine. In this clinical review, we propose and describe: (1) A common clinical profile in aid to clinical diagnosis for spectrum of complicated migraine; (2) How it can be used in differentiating complicated migraine from migraine without aura, migraine with aura, and seizure; (3) We discuss the status of complicated migraine in the International Headache Society classification 2013; and (4) In addition, a common treatment strategy for the spectrum of migraine has been described. To diagnose complicated migraine clinically, it is imperative to adhere with the proposed profile. This will optimize the use of investigation and will also avoid a legal implication of delay in their management. The proposed common clinical profile is incongruent with the International Headache Society 2013. Future classification should minimize the dissociation from clinically encountered syndromes and coin a single word to address collectively this subtype of migraine with an acute presentation of a common clinical profile.

Migraine associated with gastrointestinal disorders: review of the literature and clinical implications

Recent studies suggest that migraine may be associated with gastrointestinal (GI) disorders, including irritable bowel syndrome (IBS), inflammatory bowel syndrome, and celiac disease. Here, an overview of the associations between migraine and GI disorders is presented, as well as possible mechanistic links and clinical implications. People who regularly experience GI symptoms have a higher prevalence of headaches, with a stronger association with increasing headache frequency. Children with a mother with a history of migraine are more likely to have infantile colic. Children with migraine are more likely to have experienced infantile colic compared to controls. Several studies demonstrated significant associations between migraine and celiac disease, inflammatory bowel disease, and IBS. Possible underlying mechanisms of migraine and GI diseases could be increased gut permeability and inflammation. Therefore, it would be worthwhile to investigate these mechanisms further in migraine patients. These mechanisms also give a rationale to investigate the effects of the use of pre- and probiotics in migraine patients.

Clinical implications for breath-powered powder sumatriptan intranasal treatment

The acute treatment of migraine requires matching patient need to drug and formulation. In particular, nausea and vomiting, quick time to peak intensity, and the common gastroparesis of migraineurs, all call for a variety of non-oral formulations for treatment of attacks. A novel breath-powered powder sumatriptan intranasal treatment offers an improvement, at least in pharmacokinetics, over conventional liquid nasal sumatriptan spray. The device for delivery in this breath-powered nasal sumatriptan uses natural nose anatomy to close the soft palate and propel the sumatriptan high up in the nasal cavity on one side with bidirectional airflow coming out the other side. This approach has the potential to reduce adverse events and improve efficacy. Phase 3 data on this system are in press at the time of this writing and results appear promising. The clinical role for a fast acting non-oral nasal formulation will be in those for whom tablets are bound to fail, that is, in the setting of nausea and vomiting or when the time to central sensitization, allodynia, and disabling migraine is too short for the patient to respond to a tablet. This review provides a clinical perspective on the breath-powered powder sumatriptan intranasal treatment.

Gastric emptying in migraine: a comparison with functional dyspepsia

Background/Aims

Gastric stasis in migraineurs remains controversial. The aim of this study is to investigate gastric emptying (GE) time, and any associations between GE parameters and dyspeptic symptoms among patients with functional dyspepsia (FD) and migraine without any gastrointestinal symptoms during the interictal period.

Methods

We enrolled 27 migraine patients, 32 FD patients and 12 healthy people as controls, and performed GE scintigraphy as gastric function test. Gastrointestinal symptoms were evaluated in the FD and migraine.

Results

The age-adjusted mean gastric half-emptying time in FD (125.51 ± 52.55 minutes) patients was longer than in migraineurs (100.82 ± 23.94 minutes, P = 0.035) and controls (95.25 ± 23.29 minutes, P = 0.021). The percentage of gastric retention was higher in FD than in migraine. However, migraineurs did not show an obvious delayed gastric emptying or an increase of gastric retention when compared to the normal controls. The association between each dyspeptic symptom and GE parameters was not significant, but postprandial fullness and early satiety showed a tendency of delayed GE. In migraineurs, GE time did not show significant association with nausea and vomiting during interictal periods.

Conclusions

Delayed GE does not appear to be a mechanism that patients with FD and migraine have in common. Migraineurs without dyspepsia during interictal period had normal GE, and further study for association with FD should be investigated.